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M.N.S.R. 24. 



MINISTRY OF NATIONAL SERVICE. 



General Directions for the guidance of Commissioners, Deputy 
Commissioners and Members of Medical Boards. 

The work of the National Service Medical Boards will be to examine 
men in order to grade them according to their physical and mental 
fitness. 

In grading them attention will be paid to (a) the man's previous 
health, for which purpose it will sometimes be necessary to supple- 
ment his account of himself by a reference to his usual medical 
attendant ; (b) his actual physical condition, of this the Board will 
form its own opinion ; (c) the work he is doing, for information regar- 
ding this it will be necessary in some cases to refer to the man's em- 
ployers. 

The following grades are hereby authorised : — 

Grade 1. — This Grade will comprise those who attain the normal 
standard of health and strength and are capable of enduring 
physical exertion suitable to their age. The men must not 
sutler from any organic disease, with certain exceptions 
specified hereafter, and must have no grave physical disability 
or deformity. Minor defects, such as of the teeth and of eye- 
sight, which can be removed or compensated for by artifi- 
cial means will not be regarded as disqualifications. 

Men who fulfil the conditions of Grade 1 will also be fit for 
general service in the Army. 

Grade 2. — In this Grade will be placed those who, for various 
causes, such as being subject to partial disabilities, or being 
near the maximum age, or perhaps beyond it in signs of wear, 
do not reach the standard of Grade 1, but are nevertheless 
physically able to do vigorous work. Men in this Grade 
should be able when trained to march five miles with ease, they 
must have fair hearing and vision, and they must possess 
moderate muscular development. 

As regards Military Service, men in Grade 2 should be fit 
at once either for service at home or garrison duty abroad, 
and some of them will sooner or later become fit for genera] 
service. 

Grade 3. — Men in this Grade will be those who, at the time of 
examination, are not considered fit to undergo military training 
as fighting men, but will be fit for one or other of the auxiliary 
services connected with the Army, or to continue within the 
Army the work on which they are already employed or its 
equivalent. Examples of men suitable for this Grade are those 

(B 13565) Wt. 12800— g462 9m 3/18 H & S 



with badly-deformed toes, severe flat foot, and some cases 
of hernia and of varicose veins. Other instances of those who 
should be placed in this Grade are indicated later under the 
headings of the various diseases and disabilities. The third 
Grade will also include those who are fit only for clerical and 
other sedentary occupations, such as tailoring and boot- 
making. 

The Chairman of the Board will enter on the Medical His- 
tory Sheet, in a space provided for the purpose under the head 
of Grade 3, whether the man is fitted for auxiliary service with 
troops, labour or sedentary occupations (including those of 
tradesmen and clerks). r . 

As a general indication of the non-combatant services for which men 
are required in the Army the following notes are published : — 

Note 1. — " Auxiliary service with troops. 5 ' This will include 
those Grade 3 men who are sufficiently active physically and 
mentally to accompany troops and act, for example, as Sani- 
tary Inspectors, Batmen, Cooks, Storekeepers, Butchers, 
Clerks ; or for various Non-combatant duties such as Mechanics, 
Packers, and with Balloon Parties, Grooms, Drivers, Bakers, 
Loaders, Accountants, Storekeepers, Dispensers, Cutlers, 
Operating Room Attendants, Orderlies, Men accustomed to 
the care of horses, Farriers, Shoeing Smiths, &c, &c. 

Note 2. — " Labour." This will include the less mentally alert 
or older men who are fit rather to work in Camps than with 
moving troops. These men should be able to walk a distance 
of five miles, and be in every respect fit to do the ordinary 
work of a labourer. Men to be employed as Bricklayers, 
Masons, Carpenters, Joiners, and Navvies would be included 
in this Grade. 

Note 3. — " Sedentary Occupations." These will include men who 
for any reason are unable to walk a distance of five miles. 
If they have had a fair education and can write legibly they 
can be made use of as Clerks. 

Grade 3 has also been adopted as a temporary classification of such 
men called up under the M.S. (Review of Exceptions) Act, 1917, as 
cannot for various reasons be at once graded. Further particulars 
will be found in National Service Instruction No. 19 of 1917 reprinted in 
Appendix I. 

Grade 4. This Grade will include all those who are totally and per- 
manently unfit for any form of military service. {See Appendix II.) 

The Obviously Unfit. Whenever an A.D.R. is satisfied that a man 
is obviously and permanently unfit for any form of military service he 
will submit a statement of the man's disability to the Deputy Com- 
missioner of Medical Services. If the latter is satisfied that no purpose 
would be served by having the man medically examined the A.D.R. 
will issue to him a discharge certificate (M.N.S. Form R. 2079). If the 
D.C.M.S. is not satisfied that the man's disability is of such a character 
as to unfit him permanently and totally for any form of military ser- 
vice he will be called up for medical examination and graded or discharged 
accordingly. 

d; of d; 

APR 17 1918 



The correspondence between the National Service grades of fitness 
and the classification of men by categories now in force in the Army 
i^^^ollows : — 

Grade I ... ... ... ... ... ... Category A. 

Grade II Category B(i). 

Grade III. Fit for Auxiliary service with Category B(ii). 
troops. 

Grade III. Fit for Labour Ditto. 

Grade III. Fit for Sedentary Occupation ... Category B(iii). 

DUTIES OF COMMISSIONERS OF MEDICAL SERVICES. 

1. The Commissioners will represent the Chief Commissioner of 
Medical Services in the Regions to which they are appointed, and will 
be responsible to him for the organisation and administration of the 
Medical Services within their Regions. 

2. They will keep in touch with the Medical profession in their 
Regions, and will nominate the Members of the Medical Boards 
after advice from the representative members of the local pro- 
fession in the Areas served by these Boards. They will bear in mind 
the general policy of the Ministry, namely, to appoint local men of 
good professional standing, forming a panel of practitioners to serve 
on each Board. The Chairman and Members of the Board will prepare 
a Schedule of the days and hours of attendance for the Commissioner's 
approval. All nominations of medical practitioners to serve as Members 
of the Boards will be submitted for confirmation to the Ministry. The 
appointment of Chairman will be made from the Ministry. 

3. In order to have a reserve of medical men on the panel available 
for the setting up of additional boards when necessary, the Com- 
missioner of Medical Services, in co-operation with the Deputy Com- 
missioners and the Local Medical War Committee, will make it known 
to the civil medical practitioners of his Region that there are vacancies 
on these boards, and will invite those who are willing to join them. 
The names of those approved will be submitted by the Local Medical 
War Committee to the Central Medical War Committee for final 
approval. Their confirmation will rest with the Ministry. 

4-. They will be responsible for the efficient and punctual working 
of the Boards in their Regions, and will inspect them as often as may 
be necessary, and will submit to Headquarters on 1st January and 
1st July a formal detailed report upon each medical board in their 
Region. 

5. They will keep themselves in touch with the local officials of the 
Ministry. They will take opportunities of making themselves familiar 
with the local conditions and the social circumstances of the population 
within their Region in order to appreciate the bearing of these upon 
the health and physical fitness of the people. They will keep themselves 
informed of the methods of examination practised by the Medical 
Boards under their control. 

6. They will investigate all complaints referred to them by the 
Chairman, or otherwise communicated, as to the. examinations carried 
out by their Boards. In such cases of complaint, they will not only 
enquire respecting the alleged complaints from the Chairman and 
Members of the Board concerned, but will also see, if possible;- the per^ 

(B 13565) A 2 



sons making the complaints, and will investigate the causes of the alleged 
dissatisfaction. All complaints received at a Regional Head Office 
from men dissatisfied with the examinations made by the. Medical Board 
will be investigated and reported upon by the Commissioner. 

7. A very large number of individual cases — inquiries, complaints, 
&c. — have hitherto been dealt with at Headquarters of the Ministry 
of National Service, but in future, as directed in N.S.I. No. 43 of 1917, 
these will be referred to the Commissioners of Medical Services of the 
Regions concerned for necessary action. In the case of complaints, 
unless trivial or frivolous, a report of the action taken should be sent 
to Headquarters. Complaints made or forwarded by Members of 
Parliament will continue to be dealt with from Headquarters. 

DUTIES OF DEPUTY COMMISSIONERS OF MEDICAL SERVICES. 

1. They will act as Chairmen of Medical Boards, and will be 
responsible to the Regional Commissioner for the efficient working 
of the Boards under their control. 

2. They will take into consideration and arrange for the comfort 
of the men coming for examination. They will make arrange- 
ments that the rooms are sufficiently warmed, and by observation of 
the thermometer see that this is being carried out ; that they are well 
lighted and ventilated, and that there is no overcrowding in the dressing 
or waiting-rooms. They will frequently inspect the latrines and 
lavatories. They will see that the examinations are conducted in 
a manner consistent with the customs of the medical profession with- 
out undue haste or undue waste of time. Silence should be observed 
in the examination room, and smoking must not be allowed. It should 
be impressed upon the Examiners that they should listen attentively 
to any statements the men may have to make respecting their conditions 
or any history of previous illnesses or disease. Irrelevant conversa- 
tion should be discouraged, and any conversation or consultation be- 
tween the members of the Board, especially consultation respecting the 
medical condition of the men, should not be conducted so as to be 
overheard by men under examination or by the attendants. 

As a general rule, when there is a steady flow of men coming up for 
examination, it should be possible for an experienced Board to examine 
at least 12 men in an hour, but much will depend upon the condition 
of each individual case, and also upon the class of men being submitted 
for examination at any one period. 

Each session of a Medical Board will extend to two and a-half 
hours, but in cases of abnormal pressure the session may require to be 
prolonged. If the estimated number of recruits to be examined on 
any day is less than 40, an effort should be made in co-operation with 
the Assistant Director of Recruiting to complete their examination at 
one session of the Board. If for any reason four examiners are not 
available, the divisions of the examination may be so combined as 
to adapt it to three, or even to two, examiners, but in no case should 
a Board consist of less than two members and a chairman, but this 
must be regarded as an entirely exceptional measure. 

3. They will be informed, as long beforehand as is possible, by the 
Assistant Director of Recruiting of the number of men who are likely 
to come forward for examination, and will arrange accordingly the 



number of sessions of their Boards and the attendance of Medical 
Examiners. 

4. The Commissioner of their Region will provide the Deputy Com- 
missioners with a list of the names of the local medical men who have 
been selected to sit on the Boards under their chairmanship. They 
will then confer with the medical men so selected and arrange with 
them a schedule of the days and hours of their attendance. As a rule 
it will be found that the panel of medical men serving on the Boards 
is considerably larger than those actually required at any one session. 
In allotting their attendances, it will be advisable to arrange, if possible, 
that the Boards should vary in their grouping and on a uniform plan, 
e.g., the first Board might consist of Examiners 1, 2, 3 and 4, the second 
of 2, 3, 4 and 5, the third of 3, 4, 5 and 6 and so on till the last of the 
Examiners was reached, after which the series would begin again. 
In this way the standard of the work of the Board is likely to be kept 
more uniform than if a completely different set of Examiners attended 
different sessions. 

5. They will see that no part of the examination of the men is deputed 
to Orderlies or attendants. 

6. They will arrange a time-table of the work of the Board indica- 
ting the hours of attendance of the Members of the Board. This 
time-table will be kept and initialled by the Chairman, who will make 
every effort to ensure punctuality on the part of the members. 

7. They will prepare a daily report on M.N.S. Form 3611 of the 
examinations completed by the Board, and send it to the Deputy 
Controller of Statistics. 

8. They will keep in contact with the officials of the Ministry in the 
Area. They will make themselves familiar with the local conditions 
and the social circumstances of the population within their Areas, 
especially in so far as these affect the public health and physical fitness 
of the people. They will make immediate and special inquiry into 
any complaints or allegations of dissatisfaction with the examina- 
tions carried out by their Boards, always making an effort to see and make 
personal inquiry of the individuals who have made the complaints 
and statements expressing dissatisfaction. When necessary they will 
forward such complaints to their corresponding. Commissioners. 

9. They should encourage the members of the Local and Appeal 
Tribunals to visit their Boards in order that these may be satisfied that 
the comfort and convenience of the men coming for examination 
receive full consideration. 

10. They will not hesitate to re-examine men when the Local Tri- 
bunal requests re -examination. If re-examination is tactfully arranged 
and carried out, appeals to the Appeal Tribunal and re -examination 
by the Medical Assessors will, in the majority of instances, be rendered 
unnecessary. It is very desirable that such re-examinations should 
be made by different members of the panel. 

11. When re-examinations are to be made by the Medical Assessors 
at the request of the Appeal Tribunal, the Deputy Commissioners 
will afford every help to the Medical Assessors by producing all docu- 
ments relating to the case, and by placing at their disposal all the facili- 
ties and equipment of their Medical Boards, including the lay staffs 



When requested, Deputy Commissioners should attend the sittings 
of Assessors at which cases from their Boards are examined or else 
depute one of the members to do so. 



THE EXAMINATION. 



General Remarks on Examinations by National Service Medical 

Boards. 

Overcrowding of the examination hall should be avoided. Not 
more than four of the men to be examined should be admitted at a 
time, but the clerk who acts as usher between the dressing-room and 
the examination hall should see that four others are in readiness to 
follow. 

If, as sometimes must happen, there is a block caused, for example, 
by a prolonged examination in one or other of the bays, the further 
supply of men should be held back as long as may be necessary, other- 
wise overcrowding and some confusion will result. The several bays 
for the examiners should always be partitioned off, as this promotes 
order and quiet, and prevents the bunching together of examiners and 
men which occurs when there is no such separation. 

Consultations between Examiners should not be needlessly frequent 
as they cause delay, and in order to avoid the necessity for these, 
examiners should seek to increase the efficiency of their own methods 
so as to obtain accuracy of grading. It should always be remembered 
that while no unfit men, who will become a burden to the State, are 
wanted, on the other hand, no men who are fit must be allowed to 
evade their obligations. 

The Chairman of a Medical Board should endeavour to keep pace 
with the examiners and thus avoid a block at his table. It is both 
unnecessary and undesirable that he should re-examine every man, but 
in all cases where there is a doubtful condition which may have an effect 
on grading, he will both make an examination and consult with the 
members of the Board. The consultative and administrative duties 
of the Deputy Commissioner of Medical Services are so important and 
require so much of his time that he neglects these if he repeats in the 
case of every man the examination already carried out by the Board. 
But when the Chairman is completing the medical history sheet he will 
always see each man stripped. 

The Sectional method of examination will be followed by all Medical 
Boards, i.e., all recruits will be seen at some stage of their examination 
by each Member of the Board, but if a Member has any doubts he 
should consult with one or more of his colleagues. When the Board 
consists of four Examiners and the Chairman, a method such as the 
following is suggested : — - 

Examiner No. 1 will take the weight, height, and chest 
measurement, will note the colour of the hair and eyes, complexion, 
external marks such as scars, vaccination marks, tattooing, and any 
indication of venereal disease, or enlargement of lymphatic glands. 

Examiner No. 2 will pay attention to the physical development, 
will test the movement of the joints, will investigate deformities, e.g., 
knock-knee, flat foot, hammer toes, &c, and will inquire into the his- 



tory of injuries and operations, if any. He will examine the scrotum, 
testes, abdominal rings and perineum. 

Examiner No. 3 will test the vision and hearing and nerve reflexes, 
especially the reaction of the pupils and the knee-jerks, and will 
examine the eyes, ears, teeth, throat, and thyroid gland. 

Examiner No. 4 will examine the chest and abdomen, will make 
inquiries regarding previous illnesses such as rheumatic fever, tuber- 
culosis, &c, and the mental condition, and any circumstances bearing 
on this such as a history of fits, or of having been under treatment in an 
asylum for the insane. The urine, if necessary, will be tested at this 
stage. All specimens of urine examined for any purpose should be 
passed in the presence of the examiner. 

The Board will always consider any documents bearing on his 
case that a man may bring. 

Medical Certificates from general practitioners or consultants will 
receive full consideration. Copies should be kept of one or more of 
them, and these indexed under the name of the man to whom they 
refer. The originals should be returned to the owner if he wishes to 
have them. 

It should be difficult for anyone to make fraudulent use of a certificate 
which was not intended for him. If in any case there is reason to 
doubt the bona fides of a medical certificate a full report of the circum- 
stances should be sent to the Commissioner of the Kegion. Lists should 
be prepared of those who in any district grant large numbers of certifi- 
cates if these are not quite satisfactory. 

Each Examiner in turn will initial the Medical History Sheet of 
each recruit on the left-hand margin, and enter in pencil the Grade 
for which he considers the man fit, so far as his part of the examination 
is concerned. The Medical History Sheet must be passed from one 
Examiner to another, either directly or by a clerk. It must not be read 
by the man to whom it relates, nor should discussions regarding grading 
take place within the hearing of those to whom they relate. The 
Chairman will enter the final grading, but if he finds that he cannot 
agree with the opinion of one or more of the Examiners, he will consult 
with the full Board, and will adopt the opinion of the majority in in- 
stances where there is not unanimity. In cases where opinions are 
equally divided, the Chairman will have the casting vote. 

After the man's Grade has been entered in the Medical History 
Sheet, each man who is not rejected, i.e., placed in Grade 4, will sign 
the A.F. W. 3291 indicating his Grade, and will then return to the 
dressing-room. The entries will then be made in the Medical Register; 
the Grading Card completed, and passed to the Chairman for entering the 
classification and for his signature. 

If a case presents difficulties such as to require special methods of 
examination, as by X-rays, &c, or the opinion of someone specially 
versed in a particular department of medicine or surgery, arrangements 
must be made accordingly. Each Board should have a well worked 
out system for such consultations adapted to its own conditions, and 
as these vary considerably it is not possible as yet to lay down rules 
regarding the engagement of consultants which will be of universal 
application. Where possible the Commissioner of Medical Services 
for the Region should engage consultants to attend at the examination 
hall on days and at hours to be arranged in consultation with the 

(b 13565) a 3 



Chairman, and men whose cases require such further investigations 
will assemble at those times. It frequently happens that a medical 
board has near it a General Hospital, the resources of which for con- 
sultations have been placed at its disposal, and there is no objection 
to such an arrangement if the hospital authorities are willing to con- 
tinue it and the Commissioner is satisfied of its efficiency. 

The assistance of Tuberculosis Officers is available for the examina- 
tion of men resident in their areas, and free use should be made of 
their services. (See Appendix IV.) 



j^The men will usually enter the examination-room wearing a coat 
and slippers or unfastened boots, which can readily be removed when 
desired . 

The accuracy of the weighing-machine should be tested occasionally 
by comparing its indications* with those of other machines, or by 
loading it with a known weight, such as 14 lbs., and reading its indica- 
tion. 

. During the measurement of his chest, the man must stand erect 
with his feet together and his arms raised above his head. The tape 
is then so adjusted that its upper border touches the lower angles 
of the scapulae behind, and its lower border the nipples in front. The 
arms are then dropped to the sides, and the girth noted after both 
extreme expiration and inspiration. 

Although no minimum of height, weight, or chest measurement 
is fixed, yet men whose height is below five feet, or weight less than 
100 lbs., or chest measurement less than 32 inches, must be carefully 
scrutinised to make sure that these low standards are not due to patho- 
logical conditions. 

In inspecting the physical development and movements, some 
system is necessary in order to avoid omissions : the man should stand 
about six feet away from the Examiner, who will often show what move- 
ments he desires by going through them himself. 

I For the upper extremities the following directions may be given : — 

Extend the arms forwards with the palms upwards. 

Open and close the hand. 

Turn the backs of the hands upwards. 

Bend the wrists and elbows. 

Swing the arms round at the shoulders. 

For the lower extremities : — 

Stand on one foot, first on the sole, then on the ball of the foot 
then on the toes. If there is flat foot, observe whether the arch re- 
appears when standing on the toes. Note any defective movement 
of the me tat arso -phalangeal joint of the great toe, also any deformi- 
ties of the toes. When this exercise has been done with each foot, 
let the man stand on one foot, putting the other forward and moving 
the toe and ankle joints freely, repeating this with the other foot. He 
then kneels on one knee (there should be a mat or pad for this), then 
rises, kneels on the other knee, rises, then kneeling on both knees rises 
with a spring and leaps. 

He then swings each leg from the hips. 



He turns his back to the Examiner and touches the ground with 
his hands, thus giving the Examiner an opportunity for passing a 
hand along the spines of the vertebrae, then separates his legs for in- 
spection of the perineum, for piles or fistula. 

Whoever examines the heart and lungs will, in cases requiring it, 
put the man through the hopping exercise described later on under 
the head of " General Condition and Physique." 



1. Accommodation. — Unless special premises are built for the 
purpose, which is at present impossible, there will be a considerable 
variation in the accommodation available for Eecruiting Medical 
Boards. It is presumed, however, that there will be at least one large 
room available for use as a Board Room, where the whole of the 
examination of the recruits will take place. This room should be 
about 50 ft. by 30 ft., and should, if possible, have a dressing-room 
opening off from it. The waiting-room, " silence room " and oculist's 
room should be on the same floor, and the " silence room " should also 
open off the main examination room. It is understood that premises 
of this description will be difficult to obtain, and a larger room, e.g., 
70 ft. by 40 ft., divided off by screens or partitions, into dressing-rooms, 
waiting-rooms, :i silence room " and examination room, provides 
satisfactory accommodation. 

2. The lighting, heating and ventilation of premises used for the 
Recruiting Medical Board are important, and when choosing the rooms 
particular attention should be paid to these points. 

3. Lavatory and latrine accommodation for recruits should be 
provided. 

Rooms for Board. 

Waiting Room. — This should be large enough to accommodate 
from 25 to 30 men. It is convenient to have it situated on the same 
floor as the Board Room. This, however, is not essential, and it may 
be on the floor above or below. 

It should contain sufficient seats or forms for the waiting men, 
and a table for the inquiry clerk, who will fill up the name, date, place 
of examination, age, trade, &c, on the Medical -History Sheets of the 
waiting men. 

Dressing Room. — It is essential that the dressing-room should be 
on the same floor as and near the Board Room. If possible, it should 
adjoin the Board Room and have a door communicating with it. It 
must be sufficiently large to contain 10 or 12 cubicles in which recruits 
can undress. 

The cubicles may be made with hospital screens if wood or canvas 
and wood partitions are not available. They should each have carpet 
or matting, a chair and pegs for hanging clothes. Pairs of hospital 
slippers should be provided. If a separate dressing-room cannot be 
obtained on the same floor as the Board Room, part of the Board 
Room may be screened off by a partition not less than 8 ft. high and 
used as a dressing-room. 

Recruits should be instructed to keep their coats on when passing 
from the waiting-room to the Board Room. 

(c 13565) a i 



10 



A notice should be displayed in the dressing-room advising recruits 
to take with them in their coats any valuables they may have in their 
possession. 

Board Room. — There should be strips of cocoanut matting or 
rugs and mats for the recruits to walk on, who at this stage of the 
examination will be barefooted. Special attention must be paid to 
heating as the men will be stripped. 

Suggested Arrangements of Medical Board Room. 

(See Plan.) 



Couch 



it 1 



SileivceRoom 



o 
q 



Y 



rz 



Ocuus ts Room 

2l'*6' APPROX: 



TABLE 



CORRIDOR 

i i'o' 1 i'o" 



30- 



Couch 




, — 


6*2i' 






o 

s0 


N?- 


4- 


. 


b 




TABLL 





Exam? Bay 



M?3 



"O N9S 



WEIGHING MACHINE- 
HEIGHT STANDARD-! 



\o M?l 



TABLL 



E 



TABLE. 



ClebkS 

TABLE 



W 

*&&. 



3'o" 



-Tlrranatmtnf of 'Examination Hoom Jor JVecficaf Soard- ^ 



6x0.' 



PRESIDENTS 
TABLE 



CLERKS TABLE 



LAVATORY 1 

I ooo I C 



3 



-<o' &- 



>- 



The Board Koom should contain four examination bays. This 
may be arranged by means of hospital screens if canvas and wood 
partitions are not available. Each bay should be about 11 ft. by 
6 ft. The Chairman's table should be so placed that he can see all 
that goes on during the examination. 

In No. 1 Examination Bay the instruments for taking the height 
and weight are placed, and at this period of the examination all the 
necessary measurements should be taken. 

It is suggested that the examination of the heart and lungs should 
be performed in No. 4 Bay, where a couch should be placed, and it 
should be possible for the recruit to be easily taken from this bay to 
the silence room provided for the examination of difficult cases. 

If a silence room, opening off the Board Boom, is not available, 
it may be improvised with screens or partitions in the quietest part of 
the Board Room. 

A urine-testing table and washing accommodation for the Chairman 
andJMembers should be placed in the Board Room. 



11 

Each Chairman should be supplied with a lock-up box or cup- 
board, and at least 8 files for documents. 

The vision testing may be carried out in the oculist's room, if one 
is available : if not, it may be carried out in the Board Room. 

Silence Room. — Should be at least 10 ft. by 8 ft. It should be 
provided with a couch or bed for examining recruits, a small table and 
a chair. 

Oculist's Room. — If this is provided it should be at least 22 ft. 
by 6 ft. 

Private Examinations. — The Chairman will arrange for these 
when desirable. 



Equipment for Board. 

Screens for examination cubicles. 
Cocoanut matting for floor in strips. 
Couches for bays. 

Tables for Chairman, Members and Clerks. 
Chairs. 

Weighing machines. 
Height-testing machines. 
Tape measures. 

Snellen's types (for testing vision) (three boards). 
Sets of lenses for refractions, an obturator. 
Stands for testing urines. 
Brunton's auroscope. 
Nasal speculum and mirror. 

Washing accommodation for President and Members, with means 
of heating water. 



Clerical Establishment. 

Clerical Establishment : Six clerks will usually be provided for 
each Medical Board, one of whom will occupy a table near to the 
Chairman, two will be engaged in the preparation of the Medical History 
Sheets, Grading Cards and the Medical Register, the third will maintain 
order in the waiting-room and keep up a steady supply of men from 
this to the dressing cubicles and see that these do not become over- 
crowded. Of the two remaining clerks, one will assist Examiner No. 1, 
and one will act as attendant in the examination room. 

The clerks employed by the National Service Medical Boards will 
l>e supplied by the Assistant Director of Recruiting of the Area. For 
purposes of office discipline they will be under the orders of the Deputy 
Commissioner of Medical Services, who in the case of inefficiency or 
misconduct may, if he sees fit, suspend a clerk from duty and report 
the circumstances to the Assistant Director of Recruiting for action. 
(N.S.I. No. 2 of 1917, Appendix II.) 

The hours of attendance of the clerks will be regulated by the 
Chairman, but they should be present half an hour before the arrival 
of the Members of the Board in order that all documents may be ready 
at the beginning of the session. 

An attendance book will be signed by each clerk on arrival and 
departure. 



12 

Medical History Sheet.— This is a document of great importance, 
and it is the basis upon which all claims for disability pension are 
considered on a soldier's discharge from the service. Any failure 
of officers concerned to give attention to the preparation and main- 
tenance of these documents, and any inaccuracy in, or insufficiency of 
the entries therein, will almost certainly cause considerable delay, 
much expense, and grave injustice to the soldier. Accordingly, Deputy 
Commissioners and Members of Medical Boards will take every care 
to ensure that all necessary entries are carefully and accurately made. 
' Marks " and slight defects are to be noted concisely and clearly 
in the space allotted for this purpose, in order to facilitate the man's 
future identification ; and special attention should always be drawn 
to the defects which may cause a man to be classified in one of the 
lower Grades, or which may influence decision on possible claims for 
pension in the future : these should be described as in a clinical report. 

Conflicting Gradings.— The last authorised medical examination 
supersedes all previous examinations, and accordingly the Grade in 
which the man is placed at his last authorised examination will alone 
be recognised. 

Pending the preparation and issue of a revised form of Grade Card, 
existing stocks of the Medical Classification Army Form W 3291, 
issued by the Army Council, will continue to be used, but the Com- 
missioners and Deputy Commissioners will be held responsible that 
all existing stocks of the certificate will be altered by deleting the 
capital letters A, B, C and R.R. When any such certificate is issued, 
the appropriate grade into which the man is placed will be inserted in 
red ink in words and figures — thus, Grade 1 (one). The Certificate 
will not be issued in the case of Grade 4. The words " Classified " or 
" Classification " wherever they appear will be altered to " Graded ' : 
or " Grade," as the case may be. The books of certificates and their 
counterfoils will be considered as confidential documents in all respects, 
and when not in actual use must be kept under lock and key. Com- 
missioners of Regions will periodically inspect and check the serial 
number of classification books to ensure that no irregularities have 
occurred and that certificates are not being improperly used or 
abstracted. 

Classification certificates and Grade Cards will be signed by the 
Deputy Commissioner as Chairman of the Medical Board, who is 
responsible for the accurate preparation and completion of all the 
necessary documents. He will be responsible for seeing that the Grades 
and Categories not applicable are struck out in red ink, and the proper 
Grade or Category is inserted in red ink, and that the description of 
the man and all details are properly completed, including the signature 
of the man, before he parts with the certificate. He will initial the 
counterfoil and be responsible for its correct completion, and will 
attach the first counterfoil to the man's medical history sheet. The 
man must sign the certificate or Grade Card as well as the stub counter- 
foil in the spaces provided for the purpose. If he refuses to sign, the 
certificate or card will not be issued to him. If unable to write, the 
man must make his mark in the presence of the Deputy Com- 
missioner. 

Whenever a man is re -graded, his previous Grade Card or Classifica- 
tion Certificate must be destroyed by the Deputy Commissioner at the 



13 

time of the examination before the issue of the new Grade Card or 
certificate, or, in the case of a man placed in Grade 4, the issue of a 
discharge certificate. 

When a man in possession of a previous certificate of discharge 
from Naval or Military Service is re-examined under the Review of 
Exceptions Act, 1917, and is placed in any of the first three Grades, 
he will receive his appropriate Grade Card, but in order to prevent 
the use of his previous discharge certificate as a protection from 
recruitment, such certificate will be endorsed by the Deputy Commis- 
sioner " Re-examined on the , 191 , under 

the M.S. (R. of E.) Act, 1917, and graded in Grade No . 

Effect upon Gradation of Common Disabilities and Diseases. 

To assist Chairmen and Members of Medical Boards the following 
epitome has been drawn up indicating the usual effect upon gradation 
of common disabilities and diseases. A minimum of mental capacity 
is assumed for all Grades. Those failing to attain this minimum should 
be considered as unfit, for their usefulness to the State will be so limited 
as to make it unnecessary or uneconomical to call upon them for service. 
In doubtful cases enquiry should be made as to the Standard they 
attained on leaving school and their wage-earning capacity. 

The statements are not intended to bind Chairmen and Members of 
Boards to place a man in the suggested Grade, for it is recognised that 
each case must be decided on its merits. They are to be regarded 
only as a guide for Chairmen and Members of Boards to assist them and, 
so far as is possible, to ensure uniformity in the grading of men through- 
out the country. 

General Condition and Physique. 

These must be considered for every Grade. Often the man's occupa- 
tion, such as that of blacksmith, navvy or miner, or the exercise he 
takes, such as football, cycling, walking, or the distance he covers by 
walking or cycling in a day's work will show that he will be able to do 
the physical work of Grades 1 and 2. But sometimes the Examiners 
will have no such guides, and then they may be doubtful as to the man's 
capability for physical exertion. Under these circumstances it may be 
well to see how he responds to such exertion as can be performed before 
the Board. The most suitable form is hopping, carried out in the follow- 
ing manner : — 

(1) The man's pulse rate is taken while he stands at rest ; 
2) He hops 20 times with the right and then 20 times with the 
left leg, always lifting the foot about 9 inches from the 
ground, without a pause ; 

(3) Immediately after this the movements of the chest and of the 

aloe nasi should be observed while the man's attention is 
distracted by conversation. In health there should be 
no noteworthy breathlessness, and no pallor nor anxiety of 
expression ; 

(4) The rate of the pulse is taken two minutes after the exercise, 

and while the man still stands. In health it should not 
be more than five beats more than it was before the exercise. 
Acne. 

Most men affected with acne should be accepted for service, and 
graded according to their physical fitness. Very severe cases, especially 
those in whom the back is badly attacked, should be placed in Grade 3. 



14 

Albuminuria. 

In a young subject albumen in the urine is not in itself a disqualifica- 
tion for Grade 1, but care should be taken to determine that it is not 
due to organic disease. 

Appendicitis . 

The mere complaint of pain and tenderness in the iliac fossa on 
the right side is no bar to the man being placed in the Grade other- 
wise suited to his physical condition, nor is a trustworthy history 
that the man has had an attack of acute appendicitis unless it has 
occurred within two months, in which case his examination should be 
temporarily deferred for a suitable period. A scar after an operation 
for appendicitis is of no importance unless there is undoubted ventral 
hernia, in which case the man should be placed in Grade 3. 

Asthma. 

Cases of well-verified, genuine, spasmodic asthma, in which the 
attacks occur monthly, or more frequently, should not be placed higher 
than Grade 3, but if they occur at longer intervals, and there is no 
evidence of shortness of breath, bronchitis or emphysema, the man 
may be placed in Grade 2. 

Bronchitis. 

No man suffering from chronic bronchitis, of which physical signs 
can be found in the chest, should be placed higher than Grade 3. 

Cleft Palate. 

If this interferes with clear articulation, the recruit should be placed 
in Grade 3. 

Club Foot. 

If a man is able to walk fairly, and his general health is good, he 
may be placed in Grade 3 for employment on the same kind of work 
to which he is accustomed in civil life. 

Colitis. 

Colitis is to be judged by the severity of the symptoms. The mere 
passage of mucus is no bar to the Grade for which the man is other- 
wise suitable. 

Corns. — Painful Corns on the Soles of the Feet. 

If these are associated with pes cavus, hammer toes, or toes other- 
wise deformed, no permanent cure can be expected from treatment 
of the corns only, hence such cases are seldom fit for a higher Grade 
than Grade 3. 

Deafness . 

If the man can hear a soft, not forced whisper at a distance of 
6ft, with each ear, the other being closed, he is fit for Grades 1 and 2. 
If he cannot hear, care must be taken that the failure is not due to the 
presence of cerumen (wax). 

A man who cannot hear the spoken voice at a distance of more 
than one foot in one or other ear when he is not looking at the Examiner 
should be placed in Grade 4. 

Those falling between these two classes should be placed in Grade 3. 
It is to be remembered that in some cases the man may be suffering 
from a cause producing loss of hearing which is merely of a transitory 
character, e.g., Eustachian and middle ear catarrh following a cold. 
He may then be classified in Grade 1 or 2, as if the diminution of hearing 
did not exist. 



15 

A man with complete unilateral deafness is usually without the 
sense of the direction from which sounds proceed, and it is then advisable 
to place him in Grade 3. 

The presence of an old perforation with a dry ear is of no import- 
ance, and the case must be judged solely on the degree of deafness. 

In cases of previous simple mastoid operation (Schwartz's) or 
radical mastoid operation, if the result is satisfactory, the amount of 
hearing will determine the Grade, for these operations in themselves 
•do not disqualify for any Grade. (See Otitis Media.) 

Diabetes. — See Glycosuria. 

Duodenal Ulcer. — See Gastric Ulcer. 

Epididymis. — See Tuberculosis of Testis. 

Eczema. 

A man suffering from ezcema of long standing, affecting a large 
surface and resistant to treatment should not be accepted for service. 
Mild attacks of the disease not affecting parts of the body liable to 
pressure from clothing and equipment should be graded according to 
their phsyical fitness. Cases of moderate severity should be placed in 
Grade 3, so that they may be employed on work similar to their ordinary 
trade or avocation. 

Epilepsy (Both Grand and Petit Mai). 

If a man states that he is the subject of this disease, but no attacks 
have occurred for seven years, and there are no marked symptoms of 
instability of the nervous system, e.g., greatly exaggerated knee jerks, 
widely dilated pupils or tremor, he may be placed in the Grade for which 
he is otherwise suited. If the symptoms of instability are present, he 
is at best fit only for Grade 3. If he is said to have had epileptic attacks 
during recent years, and there is definite evidence that these have 
not been severe or frequent, and there is no evidence of instability of 
the nervous system, he may be placed in Grade 3 to do work similar 
to the occupation to which he is accustomed. 

No epileptic in whom the attacks are severe or frequent, or who 
has well-marked evidence of instability of the nervous system or any 
evidence of mental deterioration, is fit for Grades 1, 2 or 3. 

Certificates, if possible, should always state whether the certifier 
has seen an attack or its immediate results, and whether he knows 
of other cases of epilepsy in the family. 

Eye (Diseases of). 

Unless the effect upon gradation is obvious, these cases should be 
referred for special examination. (See also Standards of Vision.) 

Favus. 

This disease is contagious, and when it affects the scalp is highly 
resistant to treatment. Cases affecting large areas of the scalp should 
not be accepted for service. Less severe cases may be placed in Grade 3, 
the presence of the disease being noted, so that care may be taken 
to prevent contagion, and to institute treatment. 

Fistula in Ano. 

If a man refuses operation, but is earning his living in civil life, 
he may be placed in Grade 3, for employment in an occupation similar 
to that to which he is accustomed. 



16 

Flat Foot. 

If the joints of the tarsus are flexible and the arch re-appears when 
the man stands on tiptoe, the flat foot is no bar to Grade 1. If the foot 
is everted and the tarsal joints are stiff, he should be placed in Grade 3. 

Gastric and Duodenal Ulcer. 

If a man gives a history or brings a certificate suggesting the exist- 
ence of an ulcer of the stomach or duodenum, and has undoubtedly, 
had hsematemesis or meleena within a recent period of time, the presence 
of an ulcer may be assumed, and he should be placed in Grade 4 or 
deferred for six months. The mere complaint of indigestion with abdo- 
minal pain, even if extending over some years, is no proof of the presence 
of an ulcer, and many men with these symptoms may be placed in 
Grades 1 or 2. 

Glands (Enlarged Glands in the Neck). 

Scars due to operation on or suppuration of glands in the neck 
are in themselves no bar to Grade 1 . 

Glycosuria. 

If the urine gives a definite red or yellow precipitate with Fe tiling's 
fluid, the man is unfit for Grades 1, 2 or 3. If he brings a certificate 
stating that he is suffering from diabetes or glycosuria, and no sugar 
is found in the urine, enquiry should be made from his doctor as to 
whether he is on special diet or not, and if satisfactory evidence is forth- 
coming that the man has diabetes, he should be rejected. 

Gonorrhoea. 

If a man is found to have gonorrhoea, he should be placed in the 
Grade for which he is otherwise suited, a note being made on his medical 
history sheet. 

Men who require the periodic employment of a bougie or catheter 
for purposes of treatment of a definite stricture must not be placed 
higher than Grade 3. If other complications of gonorrhoea are present,, 
the examination of the man may if necessary be deferred. 

Hammer Toes. 

No general rule can be laid down, but if there are painful bursa? 
or corns on the dorsum of the toes, and the man walks on the tips of 
the affected toes, it is useless to attempt to drill or train him, and he 
should be placed in Grade 3, otherwise the subjects of hammer toes 
are fit for Grade 1 . 

Heart (Diseases of the). 

In all cases the heart should be examined with the man in both 
erect and lying positions. A systolic murmur is not necessarily an 
indication of disease of the heart. Most systolic murmurs heard only 
at the base of heart and systolic murmurs wherever located which 
disappear during full sustained inspiration do not indicate cardiac 
disease. If a systolic murmur definitely indicative of mitral regur- 
gitation is present, the man should not be classified in Grade 1 . 

A man with a well-compensated mitral regurgitant murmur who 
shows healthy response to the exercise test already given may be placed 
in Grade 2, unless he has recently had a well-certified attack of rheu- 
matic fever. 



17 

A man with a mitral regurgitant murmur and showing but slight 
enlargement of the heart and no signs of failing compensation, e.g., 
oedema of the feet; dyspnoea on slight exertion, and who is able to 
follow his civil employment, may be placed in Grade 3 for light or 
sedentary work. 

Cases of mitral stenosis are, under the most favourable circum- 
stances, fit only for sedentary work. 

No man suffering from aortic regurgitation is fit for Grades 1, 2 
or 3. A systolic murmur at the base does not necessarily indicate 
aortic stenosis. Aortic stenosis apart from regurgitation is rare, and 
cases in which it is suspected should be referred for special examina- 
tion . 

Enlargement of the heart is always pathological. Examination 
to determine the size of the heart should always be made with the 
man lying down. A diffuse impulse is not to be taken as a reliable 
sign of enlargement of the heart. 

Irregularity of the heart is not necessarily evidence of disease. 
Variations in the pulse rate with respiration and dropped beats are 
common irregularities, and of no special pathological significance. 
They disappear when the rate of the heart is raised by exertion, irregu- 
larities indicating disease do not. 

If it is suspected that a man has taken drugs with a view of altering 
the action of the heart, he should be referred for observation. 

(See also Tachycardia.) 

Hernia (Inguinal). 

If unilateral, not large and well retained by a truss, this condition 
does not disqualify for Grade I ; if bilateral, and not large and con- 
trolled by a truss, the man may be put in Grade 2. If the hernia, 
either single or double, is large with patulous rings, but is retained 
by a truss, the man must be placed in a Grade below the first, the 
precise Grade being determined by a consideration of his age and 
vigour. If the hernia is irreducible, place the recruit in either Grade 
3 or 4. 

Hernia (Femoral). 

If this is reducible and retained by a truss, the man may be placed 
in Grade 2, otherwise he should be placed in Grade 4. 

Hernia (Ventral). 

If this is not large, and is protected by a pad, the man may be placed 
in Grade 3, otherwise he should be placed in Grade 4. 

Hydrocele. 

If this is small, it is not a disqualification for Grade 1 . It is seldom, 
if ever, a reason for rejection. 

Incontinence of Urine. 

If this is not due to organic disease, and if the man is at continuous 
work* he should be placed in the Grade otherwise suited to his physical 
condition. 

Index Finger (Loss of) . 

If the grip of the hand and the movements of the fingers are but 
little impaired, the loss of a part or the whole of the index finger 
is no bar to Grades 1 or 2. 



18 

Infantile Paralysis (Wasted and Poorly-Developed Limbs). 

These conditions are almost always the result of infantile paralysis, 
and unless slight should be dealt with in the same manner as cases 
of club foot. 

Insanity. — See under Mental Diseases. 

Kidney (Movable). 

This condition is not a disqualification for Grade 1 if the man is 
otherwise physically fit. 

Kidney (Removed). 

A man from whom a kidney has been removed should not be placed 
higher than Grade 3. The urine should be examined. 

Knee-Joint (Loose Cartilage in the). 

If the diagnosis is beyond doubt, and the knee certainly locks at 
times, the man cannot be placed higher than Grade 3 . 

Limb (Loss of, Total or Partial). 

Anchylosis, shortening, curvature of a long bone, old unreduced 
dislocation, abnormal mobility of a joint, may require the subjects of 
any of these to be placed in Grades 4 or 3 according to the greater or 
less interference with functional activity. A man who has lost an arm 
or a leg may be a good clerk, but any man who has lost the whole or 
part of a limb should not be placed even in Grade 3 except at his own 
desire, and if fit to do the work for which he has been trained. 

Lung (Tuberculosis of the). 

No man with active tuberculous disease of the lungs should be 
regarded as fit for Grades 1, 2, or 3. In examination of men suspected 
to suffer from tubercular disease of the lungs, attention should be 
paid particularly to the presence of localised crepitations, the rate of 
the pulse, loss of weight, night sweats, temperature and the examina- 
tion of the sputum for tubercule bacilli. 

A man showing signs of past or suspected tuberculous disease of 
the lungs, and who gives a history of at least two years of good health 
may be placed in Grade 3 . Those with a shorter history of good health 
should have their examination deferred for six months. (See Appen- 
dix IV.) 

Lupus Vulgaris. 

Mild cases of this disease, affecting surfaces other than the face, may 
be placed in Grades 3 or 2. Severe cases, especially if ulcerating or 
affecting the face in Grade 4-. 

Mental Diseases. 

Attention has already, under the head of " General Directions," been 
drawn to the fact that a certain degree of mental fitness is required of 
all recruits for Grades 1, 2 or 3. Men who have at any period of their 
lives been inmates of asylums as persons certified to be of unsound 
mind, and those who at the time of examination show symptoms of 
mental disease, should be rejected. 

The reaction of the pupils and the knee jerks should be tested in 
every recruit. All cases of tabes and general paralysis should be 
rejected, however early the disease may be. 



19 

Nasal Obstruction and Catarrh. 

If there is no suppuration in the accessory sinuses, or no serious 
obstruction to breathing, the man may be placed in the Grade for 
which he is otherwise suitable. 

Neurasthenia. 

In the case of many men who complain of this condition, it is slight 
in degree, and should not be considered as a bar to Grade 1. Severer 
cases should be graded or rejected on the evidence tendered and found 
of nervous instability. 

Obesity. 

If not accompanied with visceral changes,, is compatible with 
Grades 1 or 2, but if excessive with Grade 3 only. If obesity is com- 
plicated with visceral changes, as of the heart and liver, it is a cause of: 
rejection. 

Otitis Media (With Discharge from the Middle Ear). 

The classification of many of these cases will depend upon the 
degree of deafness, but the following considerations must be borne in 
mind. 

The mere presence of a discharge does not exclude recruits from 
the Grade otherwise suited to their general physical condition. Those 
with a foul discharge and symptoms indicating involvement of the 
internal ear, e.g., headache or vertigo, should be placed in Grade 4. 
If there is a marginal perforation of the drum with granulations of the 
polypi, or granulations alone, the man should be placed in Grade 4. 
(See under Deafness.) 

Piles. 

In the majority of cases this malady is not of sufficient severity to 
have an effect on the man's grading. If they protrude and bleed, and 
the man refuses to have his condition cured by operation, and if he is 
able to work, he should be placed in such a Grade as will permit of his 
being employed in similar work in Military Service. 

Psoriasis. 

Psoriasis mild in type and occurring in small patches does not prevent 
a man from being placed in the Grade suited to his physical fitness. 
More severe cases should be placed in Grade 3, but those affected with 
widespread psoriasis of long duration should be placed in Grade 4. 

Renal Calculus. 

A man who has undoubted symptoms of stone in the kidney should 
be rejected or have his examination deferred until such time as his 
actual condition can be ascertained. If an interval of six months has 
elapsed without symptoms, and the skiagram shows no abnormality, 
he may be placed in Grade 1, 2 or 3, according to his physical condition, 

Rheumatism (Chronic). 

A young man who brings evidence of occasional attacks of muscular 
rheumatism may be placed in Grade 1, but if over 35 years of age he 
should not be put in a higher Grade than Grade 2. Men suffering from 
chronic articular rheumatism should not be placed higher than Grades 
2 or 3. 

Scabies and Pediculosis. 

These diseases do not affect the classification of a man. A man 
suffering from these maladies should be placed in the Grade for which 
he is otherwise physically fit. 



20 

Spinal Curvature. 

Angular curvature is almost always the result of tuberculous caries. 
If the disease is active, or recently active, the man must be rejected. 
If there have been no active symptoms for four years, and the man has 
been following a trade, he will often be found fit for Grade 3, to be em- 
ployed in a similar occupation to that which he is accustomed to follow. 

A moderate degree of dorsal curvature (kyphosis) is not a disqualifi- 
cation for Grade 1 if the man is otherwise fit for this Grade. 

i Lateral curvatures, unless causing persistent pain or severe deformity, 
need have no effect on gradation. 

Stammering. 

This is not a disqualification for Grades 1 or 2 unless of extreme 
degree. Evidence should be obtained that it has been in existence 
for some time and is well known to the man's associates. 

Sycosis. 

Severe or recurring cases of this disease should not be placed higher 
than Grade 3, an entry being made on B 178 that they may require 
treatment. Mild cases may be graded according to their physical 
fitness in other respects. It should be remembered that many cases 
described as sycosis are not cases of folliculitis, but a suppurating 
condition of the surface of the type of impetigo, and these are readily 
amenable to appropriate treatment. 

Syphilis. 

If a man has, or has had, syphilis, he must be classified according 
to his general physical condition. If the infection is recent, he should 
be recommended to have his disease properly treated. If the man has 
severe or long-standing syphilitic disease which has caused injury or 
destruction of tissue or disease affecting important organs such as the 
heart, blood vessels, or the nervous system, he must be classified accord- 
ing to the degree of disability produced by the disease, or in the severer 
cases of the malady he may have to be rejected. 

Tachycardia (Rapid Action of the Heart). 

A pulse rate up to 120 per minute is often, especially in youths, 
merely due to the excitement of examination, and in the absence of 
evidence of diseases producing a rapid pulse it may be disregarded. 

Paroxysmal Tachycardia. 

Is very rare. If this condition is suspected the man should be referred 
for special examination. 

Teeth (Deficiency with or without Pyorrhoea). 

This condition alone should not be regarded as affecting classifica- 
tion except in those cases in which there is distinct evidence of secondary 
disability or disease, which in themselves would act as disqualifications. 

Testicle (Undescended). 

If the testicle is entirely retained in the abdomen on one or both 
sides, and there is no other defect of sexual development, the man 
may be placed in Grade 1. If a testicle is in the inguinal canal or at 
the external ring on one or both sides, and therefore exposed to injury 
or is subject to attacks of pain, the classification should not be higher 
than Grade 3. 



21 

Testis or Epididymis (Tuberculosis of). 

Sufferers from tuberculosis of either of these organs must be rejected. 

Thorax (Deformity of the). 

As extreme contraction or deformity such as a deep depression 
of the sternum is likely to interfere in training with the action of the 
heart and the expansion of the lungs, these cases are best placed in 
Grade 3. On the other hand, minor degrees are of no importance, and 
in young subjects often disappear with training. 

Thyroid Gland (Enlargement of the). 

If this condition is accompanied by symptoms of Graves' Disease, 
the man should be placed in Grade 3 or rejected. If there is no inter- 
ference with breathing nor with the action of the heart, and the enlarge- 
ment of the gland is not great and is of long duration, it should not be 
considered a bar to Grade 1. 

Toes (Deformed). 

Extreme forms of contraction, also of hallux valgus, the great toe 
overlapping or being covered by the others can only be placed in a 
sedentary grade. Hallux rigidus is fit only for Grade 3. 

Tuberculosis. (See Separate Organs.) 

Yaricocele. 

Mild and moderate cases should be placed in Grade 1. Severe cases 
with good evidence of pain should be placed in Grades 2 or 3 and advised 
to wear a suspender. 

Varicose Veins. 

If the varix is not a source of much inconvenience in standing or 
walking, it is no bar to Grade 1. More serious cases, and those with 
varicose veins above the knee, should be placed in Grade 3. Those 
with large sacculations of the veins should also be placed in Grade 3, 
and the medical examination of men complaining of much pain 
associated with the varix should be postponed. Cases of chronic 
ulceration or thin scars of healed ulcers associated with varicose veins 
should as a rule be rejected, but if the ulceration is recent and likely 
to heal, their further examination may be postponed for some months. 
Cases with evidence of, or a well-certified account of, recurrent phlebitis 
should be rejected. 

In addition to the rejections already mentioned, men suffering from 
the following conditions should be placed in Grade 4 : — 

(1) Tuberculous peritonitis. 

(2) Tuberculous laryngitis. 

(3) Tuberculous cystitis or pyelitis. 

(4) Cirrhosis of the liver. 

(5) Ascites. 

(6) Malignant disease anywhere. 

(7) Nephritis, acute or chronic. 

(8) Pernicious anaemia and all forms of leuchsemia. 

(9) Aneurism. 

(10) Tabes, general paralysis and all organic diseases of the 

central nervous system. 

(11) Sexual abnormalities such as arrested development and 

hermaphroditism . 



22 

STANDARDS OF VISION. 

1 . The standard of vision for a man who is to be trained to shoot with, 
the rifle and serve in the field, i.e., for general service, should be at least 
6/24 with one eye, either the right or left, without glasses, and at least 
6/12 with the right eye, aided, if necessary, by glasses. The strength: 
of the correcting lens in the case of sphericals should not exceed 8D, 
of simple cylindrical 4D, and of the highest meridan in combined 
sphero-cylindrical 8D 

He must also have a good field of vision, as tested by hand move- 
ment, with each eye, and not be suffering from any progressive or 
recurrent disease of the eye. 

Note. — A man fit in all other respects may be placed in Grade 1 if the 
vision of the left eye is at least 6/24 without glasses, while that of the 
right may be less than 6/60, but the eye neither totally blind nor 
missing, and the field of vision for each eye good, special attention 
being called to the standard of vision by noting on A.F. B 178 in the 
space for " Remarks " that the sight of the right eye is not good enough, 
for rifle shooting : " R.E. not good enough for rifle shooting." 

2. The standard of vision for a man who is to be trained for garrison 
duty at home or abroad should be at least 6/60 with one eye, either 
right or left, without glasses, and at least 6/18 with the right eye, aided 
if necessary by glasses. The strength of the correcting lens in the case 
of sphericals should not exceed 10D, of simple cylindrical 6D, and of 
the highest meridian in combined sphero-cylindrical 10D. 

He must also have a full field of vision, as tested by hand move- 
ment, with each eye, and not be suffering from any progressive or 
recurrent disease of the eye. 

Note. — A man otherwise fit may be placed in Grade 2 if the vision of 
the left eye is at least 6/60 without glasses and improvable to 6/18 with 
glasses, while that of the right may be less than 6/60, but the eye- 
neither totally blind nor missing, and the field of vision for each eye 
good. As in the similar case of Grade 1, a note must be made on 
A.F. B 178 that the sight of the right eye is not good enough for rifle 
shooting. 

3. The standard of vision for a man who is not to receive military- 
training, but be employed only in auxiliary services, should be at 
least 6/60 with one eye, either right or left, with or without glasses, 
the limit for correcting glasses being : sphericals not to exceed 15D, 
simple cylindricals not to exceed 6D, in combined sphero-cylindricals- 
the highest meridian is not to exceed 15D. 

He must also have a full field of vision, as tested by hand move- 
ment, with one eye, and not be suffering from any progressive or recur- 
rent disease of the eye. The other eye may be missing or totally blind. 

4. The examiner should pass as fit for Grade 1 all those who can see, 
without glasses, 6/24 with one eye, be it right or left, and 6/12 with 
the right eye, with glasses if necessary, and who have a good field of 
vision with each eye as tested by hand movement. All those who 
fail to come up to this standard, or who do so only with the aid of very- 
strong glasses, or who complain of symptoms suggestive of recurrent 
or progressive eye disease are to be referred for examination by an 
o phthalmologist . 



23 

MINIMUM STANDARDS OF VISION (SUMMARY). 

Grade 1. — With one eye, either right or left, 6/24- without glasses. 
R.E. 6/12 with glass if necessary. 
L.E. may be less than 6/60, but the eye must not be totally 

blind or missing. 
Both eyes must have good fields of vision as tested by hand 

movements. 
Strength of glasses not to exceed : — 

Spherical, 8D ; cylindrical, 4D ; sph.-cyl., 8D in highest 
meridian. 

Grade 2. — With one eye, either right or left, 6/60 without glasses. 
R.E. 6/18, with glass if necessary. 
L.E. may be less than 6/60, but the eye must not be totally 

blind or missing. 
Both eyes must have good fields of vision as tested by hand 

movements. 
Strength o* glasses not to exceed : — 

Spherical, 10D ; cylindrical, 6D ; sph.-cyl., 10D in 
highest meridian. 

Grade 3. — Either B.E. 6/60 with or without glasses, and L.E. less or 
nil. 
Or R.E. less than 6/60 or nil and L.E. 6/60 with or without 

glasses. 
The better eye must have a full field of vision as tested by 

hand movement. 
Strength of glasses not to exceed : — 

Spherical, 15D ; cylindrical, 6D, sph.-cyl., 15D in highest 
meridian. 

In all grades the eyes must be free from progressive or recurrent 
disease. 

Colour vision will be tested in the cases of candidates for the Officers' 
Cadet Wing and the Officers' Technical Training Wing of the Royal 
Flying Corps, also in boys and youths for training as seamen in the 
Royal Navy. 

For the case of men having good sight in the left eye but indifferent 
in the right see preceding page. 



APPENDIX I. 

National Service Instructions, Nos. 13, 19, and 36 deal with the 
subject of Grading, and particularly with Grade 3. N.S.I. 19 is as 
follows : — 

Medical Re-examinations under the Military Service (Review op 
Exceptions) Act, 1917. Men temporarily unfit, or awaiting 
results op Medical Examinations. 

1. A man who is being re-examined pursuant to a Statutory Order 
issued under the Military Service (Review of Exceptions) Act, 1917, 
must be graded at the time of the examination and not be required to 
submit to an adjournment or postponement of his examination before 
being graded. If a man is not graded at the time of his examination 
it may be contended that he is " not accepted for service " under this 



24 

Act, and that lie therefore cannot be called up again for medical examina- 
tion until after the expiration of six months from the date of the Statu- 
tory Order under which he is examined. It would be unreasonable 
that a man who is temporarily unfit at the time of the examination, 
but who in the ordinary course would revert to his normal condition 
in a short period, should be freed from all liability to Military Service 
for the period of six months, and accordingly in the cases specified in 
this Instruction the following procedure will be adopted by all Deputy 
Commissioners of Medical Services and National Service Medical 
Boards when re-examining a man under this Act. 

2. A man who is temporarily unfit owing to some acute transient 
affection such, for example, as bronchitis, measles, scarlet fever, render- 
ing it inadvisable for him to be subjected to a full medical examination, 
should be inspected by the Deputy Commissioner and at once placed in 
Grade 3. An entry will be made at the time in the medical history 
sheet recording the temporary affection, and a separate note attached 
that the man is to be recalled for examination on a date (to be stated 
in the note) when the temporary affection would ordinarily have ceased. 
This will be a notification to the Assistant Director of Recruiting that 
the man is not to be called up for service with the Colours in the mean- 
time, and that he is to be sent M.N.S. Form R.3509 requiring him to 
present himself for further examination on the date in the entry. 

If a complete examination is possible in the case of a man who 
is suffering from a temporary affection the examination should be 
carried out in the ordinary course and the man graded in accordance 
with his physical fitness apart from the temporary affection at the 
time of the examination. 

3. If a man is not temporarily unfit, but it is desirable to obtain 
the result of chemical, bacteriological, photographic or other examina- 
tions before a final decision is come to, the man will also be at once 
placed in Grade 3. The Deputy Commissioner will attach a separate 
note to the medical history sheet that the result of these examinations 
is awaited stating a date (allowing enough time for the examinations 
to be completed) before which the man is not to be called up for service. 
Immediately on receipt of the result of the examinations the Deputy 
Commissioner will inform the Assistant Controller of Registration 
whether a further examination is desirable or whether the grading is 
confirmed, so that in the former event the man may be sent M.N.S. 
Form R.3509 requiring him to attend for a further examination or, in 
the latter event, he may be dealt with as a man placed in the ordinary 
course in Grade 3. 

4. If a man placed in Grade 3 in the manner set forth in para. 2 
and para. 3 of this N.S.I, makes an application to the Appeal Tribunal 
for re -examination by the Medical Assessors in respect of that grading 
he will not be recalled for further examination by the National Service 
Medical Board pending the decision of the Appeal Tribunal who should 
be placed in full possession of the facts by the National Service Repre- 
sentatives. 

5. If a man placed in Grade 3 in the manner set forth in para. 2 
or para. 3 of this N.S.I, has an application for exemption pending 
before a Tribunal he cannot be compulsorily recalled for further exami- 
nation. The Assistant Director of Recruiting will in such a case inform 
the National Service Representative concerned of the circumstances 
in which the man was placed in Grade 3, in order that the Tribunal 



25 

may be aware of the facts, especially if the man declines to submit 
himself for further examination, in which case the Tribunal should be 
asked to refuse exemption. 

6. In cases of uncertainty when prompt diagnosis presents diffi- 
culties, the man will not be placed in Grade 4, which involves his dis- 
charge and requires the unanimous finding by the members of the 
Board that the man is permanently and totally disabled and unfit 
for any form of military service. 

7. The above Instructions apply only to men being re-examined under 
the Military Service (Review of Exceptions) Act, 1917. Difficulties 
requiring the postponement of the examination of men who are being 
examined otherwise than under this Act are dealt with under separate 
instructions. 



APPENDIX II. 

Before placing a man in Grade 4 it is necessary that the members 
of the Board should agree unanimously that he is permanently and 
totally unfit for military service of any form and a certificate to this 
effect (M.N.S.F. 3599) must be entered on his medical history sheet, 
either in writing or by attaching the form. 

M.N.S. Form W. 3599. 

This slip will be attached to Army Form B. 178 in all cases where 
men are certified to be permanently and totally disabled and unfit for military 
service, vide para, 10, A.C.I. 642, of 1917. 



After examination by all the members of the Medical Board assem- 
bled at 

on it is unanimously agreed 

that the man stating himself to be 

residing 

at , and described on this 

Army Form as suffering from 

, and in consequence is per- 
manently and totally unfit for military service. 

Signature of Chairman. 

Stamp of National Service Medical Board. 
Names of Members of the Medical Board. 



Pate 



26 

APPENDIX III. 

The Returns required in connection with the work of Medical 
Boards are enumerated and explained in the following National Service 
Instruction (No. 44 of 1917). 

Returns required by the Medical Department of the Ministry 

of National Service. 

These Returns should be rendered to the Secretary (Statistics), 
Ministry of National Service, Westminster, S.W. 1, in accordance with 
the instructions detailed below. 

I. The Daily Return to show the number of men by medical grades 
medically examined or re-examined by National Service Medical 
Boards will be rendered on M.N.S. Form 3611, which will take the 
place of the present Army Form W. 3611. This new Form for the 
Daily Return will consist of seven columns, containing the following 
information : — 

Column 1. — Total examinations of men who presented them- 
selves for service on this day, having received M.N.S. 3195.. 
or for direct or voluntary enlistment, and were medically 
examined or re-examined. (Not to include those shown in 
columns 2, 3 and 4.) 

Column 2. — Total number of examinations of men who receive 
a Statutory Order M.N.S. 3579 and reported for examina- 
tion or re-examination. (Not to include those shown in 
columns 1 and 4.) 

Column 3. — Total number of examinations of men in Column 2 
who were dealt with under N.S.I. 19 of 1917. (Not to include 
those shown in columns 1 and 4.) 

Column 4. — Total examinations of men who presented them- 
selves for re -examination under M.N.S. 3491, 3509, 3514, 
3526, or who presented themselves for medical examination 
or re-examination only. (Not to include those shown in 
columns 1, 2 and 3.) 

Column 5. — Total number of men refused re -examination and 
who have had M.N.S. 3491a issued to them. 

Column 6. — Number of special examinations carried out. (This 
column should include X-ray examinations by specialists 
and other re -examinations for which special payment is 
made, irrespective of whether they have been included in 
columns I, 2, 3 and 4.) 

Column 7. — Times of opening and closing Boards — 

(a) Morning. 

(b) Afternoon. 

A " nil " return must be rendered in respect of the 
days on which a Board does not sit. Such " nil ,J returns 
will be rendered in manuscript and not on M.N.S. 3611. 

M.N.S. Form 3611 will be issued to the Commissioners 
of Medical Services for distribution to the Chairmen of Medical 
Boards prior to the 1st January, 1918, in order that this 
Form may come into use on and from the 1st January, 191$; 



27 

II. A fortnightly Return in manuscript giving a nominal roll of 
men examined by National Service Medical Boards who have appealed 
and have been examined by the Appeal Tribunal Medical Assessors. 

This Return will furnish the following information : — 

(1) Name. 

(2) Grading by N.S. Medical Board upon which the appeal 

is based. 

(3) Grading by Assessors. 

(4) Remarks. (In this column should be noted the reason, 
if available, for the alteration, if any, by the Assessors.) 

When the A.F. B. 178 and other documents of a man who has 
been examined and graded by the Medical Assessors to the Appeal 
Tribunal are returned to the A.D.R. of the Area concerned, it is essential 
that these documents should be handed immediately to the Deputy 
Commissioner of Medical Services of the Board concerned for perusal, 
in order that he may abstract the necessary details of the medical 
examination for the above Return, after which these documents will 
be returned to the A.D.R. 

III. A monthly Return in manuscript showing the list of members 
of each Board and the number of Sessions attended by each. Any 
change in personnel should be noted in this Return. 

IV. A monthly Return in manuscript of all men who have been 
rejected on account of Mental Deficiency, to contain the following 
particulars : — 

(1) Full name and address. 

(2) Occupation. 

(3) Remarks, including medical aspect of case. 
The return is to be addressed : — 

Secretary (Statistics), 

Ministry of National Service, 

Westminster. S.W. 1. 

V. A quarterly Return in manuscript of Medical Equipment, 
stating the condition. 

VI. A half-yearly report by Commissioners- of Medical Services 
upon each of the Medical Boards in their Region, to be despatched on 
1st January and 1st July. 



APPENDIX IV. 



Grading of Men who are stated to suffer or to have suffered 
from Tubercular Disease of the Lungs. 

Tt has been decided that the statement that a man has — 

(a) Received treatment in a Sanatorium under the National 
Health Insurance Commissioners or a responsible medical 
authority, or 



28 

(b) Been notified to a Medical Officer of Health under the regula- 
tions of the Local Government Board as suffering from 
Consumption, 

will not in itself disqualify him from being accepted for Military Service, 
Careful inquiries should be made to verify all such statements 
special care being taken that there is no impersonation. If on the 
man's examination no signs of disease are discovered, the Deputy 
Commissioner of Medical Services should arrange for a complete 
examination of the case and for an inquiry into the medical history 
of the patient before grading. When practicable, the particulars 
of the case should be referred to the Tuberculosis Officer of the Local 
Government Board Area in which the patient lives in order to obtain 
all the relevant facts as to the condition and the medical history of 
the patient of which the Deputy Commissioner of Medical Services 
should be cognisant before the Board proceeds to settle the grade of 
the man in question. 



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